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General NPI Number Information
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NPI Number | 1225410608
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Entity Type | Individual
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Provider Name | ALEX GUSTAF PT
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Gender | Male
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Dates
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Enumeration Date | 06/23/2015
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 613 PROFIT ST
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City | AZLE
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State | TX
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Zip | 76020-2421
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Country | US
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Telephone | 682-453-7102
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Fax | 817-665-3815
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Provider Business Mailing Address
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Address Line | 8085 EAGLE MOUNTAIN DR
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City | FORT WORTH
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State | TX
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Zip | 76135-9151
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Country | US
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Telephone | 682-453-7102
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Fax | 817-665-3815
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1258595
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License Number State | TX
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